Do all ear infections need antibiotics?

The Journal of the American Medical Association published a report last week that reviewed the existing scientific literature on the standard treatment of ear infections with antibiotics. The purpose? To see if healthcare providers should be giving even fewer antibiotic prescriptions than they already are. There are a growing number of highly antibiotic-resistant bacteria so we've got a potentially big problem on our hands—no medicine to treat these germs! So, we are trying to hold off on using our antibiotic "ammunition" unless we really need to.

So, what did the report find? Up to 80% of ear infections will clear up on their own without antibiotics.  This isn't really a newsflash for most clinicians. We know that a good number ear infections will clear on their own without treatment (particularly in older kids).But, will that change how doctors and parents approach treatment of ear infections?

Here's what I currently do in my own practice. For children who are over 2 years of age, I offer the wait and see approach. I will hand a parent a prescription (ideally Amoxicillin and not a bigger gun antibiotic) and tell them to fill it if the child is not improving. However, if that older child is running a significant fever (like 102 or higher) and has other signs of a systemic infection, not just an ear infection, I would treat that child at the time of diagnosis. For kids under 2 years of age (especially if they are running a fever), I treat ear infections when there is no question that the baby has a really bad ear infection! Those kids are not verbal enough to tell a parent if they are feeling better and have a higher risk of complications from an ear infection (e.g. mastoiditis—a very serious complication where the bacterial infection invades the skull bone and requires surgical drainage and IV antibiotics) that I don't feel comfortable waiting around to see if they improve without antibiotics.

What people need to realize is that antibiotics are not risk-free. Besides the emergence of superbugs, diarrhea, yeast infections, allergic reactions are all possible (and unpleasant side effects). And, that is why I am more likely to refer to an ENT doctor for possible PE tubes than continuing to throw antibiotics at a child with recurrent ear infections.

On the other hand, ear infections are really miserable!! Most adults have no idea how much they really hurt unless they have had one beyond childhood. So here's the bottom line: look at the scientific evidence and discuss it with your doctor. If you feel comfortable supportively caring for your child at home and waiting to see if your child improves before filling that prescription, that is usually the best course. If treating with antibiotics will help shorten the duration of that pain for some kids, it is not something we can completely discount.